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During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
- A. The patient is oriented.
- B. The patient takes a hypnotic.
- C. The patient walks 2 miles a day.
- D. The patient recently became widowed.
Correct Answer: B
Rationale: The correct answer is B: The patient takes a hypnotic. Patients taking hypnotic medications are at an increased risk for falls due to the sedative effects of these drugs, causing dizziness, impaired balance, and confusion. This increases the likelihood of accidents and falls.
Incorrect Choices:
A: The patient is oriented. Being oriented does not necessarily indicate a decreased risk for falls.
C: The patient walks 2 miles a day. Regular exercise is beneficial for overall health but does not directly correlate with fall risk.
D: The patient recently became widowed. While emotional distress can affect a person's well-being, it does not directly indicate an increased risk for falls.
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The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next?
- A. Do nothing, no harm has occurred.
- B. Notify the health care provider.
- C. Complete an incident report.
- D. Assess the patient.
Correct Answer: B
Rationale: The correct answer is B: Notify the health care provider. After assessing the patient and placing them back in bed, the nurse should notify the healthcare provider to ensure appropriate evaluation and management of the patient's fall. This is important for patient safety and to prevent any potential complications or underlying issues that may have contributed to the fall. Notifying the healthcare provider promptly allows for further assessment, interventions, and necessary precautions to be implemented.
Other choices are incorrect:
A: Doing nothing is not appropriate as the patient has experienced a fall, which requires further evaluation.
C: Completing an incident report is important, but notifying the healthcare provider takes precedence to ensure immediate appropriate care.
D: Assessing the patient has already been done, so the next step is to involve the healthcare provider for further management.
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.)
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
- F. Use type B fire extinguishers for electrical fires.
Correct Answer: A, B, C, D
Rationale: The correct actions for the nurse to take in this situation are A, B, C, and D. Closing all doors helps contain the fire and smoke. Noting evacuation routes ensures a safe exit plan. Knowing oxygen shut-offs prevents fire hazards. Moving bedridden patients in their beds aids in their evacuation. Choice E is incorrect because waiting for the fire department delays necessary actions. Choice F is incorrect as type B fire extinguishers are not suitable for electrical fires, which require type C extinguishers.
A homeless adult patient presents to the emergency department with vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
- A. Respiratory rate
- B. Temperature
- C. Apical pulse
- D. Blood pressure
Correct Answer: B
Rationale: The correct answer is B: Temperature. A temperature of 94.8°F indicates hypothermia, which can be life-threatening and requires immediate attention to prevent further complications. Hypothermia can lead to decreased heart rate and blood pressure, affecting overall perfusion. Addressing the temperature first is crucial to prevent further deterioration. The other vital signs are within normal range and may not pose an immediate threat to the patient's life.
A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?
- A. Wash hands
- B. Wash wound
- C. Wear gloves
- D. Wear eye protection
Correct Answer: A
Rationale: The correct answer is A: Wash hands. This technique is crucial to prevent transmission of pathogens as hands are the most common mode of transmission. Washing hands effectively removes microorganisms, reducing the risk of infection. The other choices are incorrect because washing the wound only addresses local hygiene, wearing gloves and eye protection are important but secondary to hand hygiene in preventing transmission of pathogens.
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.)
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
Correct Answer: A,B,C,D
Rationale: The correct actions for the nurse to take in this scenario are A, B, C, and D. Closing all doors helps contain the fire and smoke, protecting patients. Noting evacuation routes ensures a quick and safe exit strategy if needed. Identifying oxygen shut-offs prevents potential fuel for a fire. Moving bedridden patients in their bed is crucial for their safety and transportability. Waiting for the fire department (choice E) is not recommended as immediate action by the nurse is necessary to ensure patient safety.